Effective with date of service Feb. 23, 2022, the Medicaid and NC Health Choice programs cover sirolimus protein-bound particles for injectable suspension (albumin-bound), for intravenous use (Fyarro™) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code J9999 - Not otherwise classified, antineoplastic drugs.
Strength/Package Size: For injectable suspension: lyophilized powder containing 100 mg of sirolimus formulated as albumin-bound particles in single-dose vial for reconstitution
Indicated for the treatment of adult patients with locally advanced unresectable or metastatic malignant perivascular epithelioid cell tumor (PEComa).
Recommended Dose: 100 mg/m2 administered as an IV infusion over 30 minutes on Days 1 and 8 of each 21-day cycle until disease progression or unacceptable toxicity. See full prescribing information for further detail.
For Medicaid and NC Health Choice Billing
- The ICD-10-CM diagnosis codes required for billing are:
- C49.4 - Malignant neoplasm of connective and soft tissue of abdomen;
- C49.6 - Malignant neoplasm of connective and soft tissue of trunk, unspecified;
- C49.8 - Malignant neoplasm of overlapping sites of connective and soft tissue;
- C49.9 - Malignant neoplasm of connective and soft tissue, unspecified
- Providers must bill with HCPCS code: J9999 - Not otherwise classified, antineoplastic drugs
- One Medicaid and NC Health Choice unit of coverage is: 1 mg
- The maximum reimbursement rate per unit is: $73.28
- Providers must bill 11-digit NDCs and appropriate NDC units. The NDC is: 80803-0153-50
- The NDC units should be reported as “UN1”
- For additional information, refer to the January 2012, Special Bulletin, National Drug Code Implementation Update and PADP Clinical Coverage Policy 1B, Attachment A, H.7 on Medicaid's website.
- Providers shall bill their usual and customary charge for non-340B drugs
- PADP reimburses for drugs billed for Medicaid and NC Health Choice beneficiaries by 340B participating providers who have registered with the Office of Pharmacy Affairs (OPA). Providers billing for 340B drugs shall bill the cost that is reflective of their acquisition cost. Providers shall indicate that a drug was purchased under a 340B purchasing agreement by appending the “UD” modifier on the drug detail.
- The fee schedule for the PADP is available on Medicaid's PADP web page.
Contact
NCTracks Contact Center: 800-688-6696